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H/A: Executive Summary of Recommendations (2010)

Executive Summary of Recommendations

Below are the major recommendations and ratings for the Academy of Nutrition and Dietetics HIV/AIDS Evidence-Based Nutrition Practice Guideline. View the Guideline Overview from the Introduction tab. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and EAL subscribers under Major Recommendations .

The Registered Dietitian (RD) should provide at least one to two Medical Nutrition Therapy (MNT) encounters per year for people with HIV infection (asymptomatic) and at least two to six (or more) MNT encounters per year for people with HIV infection (symptomatic but stable, acute or palliative), based on the following:

The registered dietitian (RD) should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that all people with HIV infection are screened for nutrition-related problems, based on referral criteria regardless of setting, at every visit. People with HIV infection are at nutritional risk at any time-point during the course of their illness.

Consensus

Imperative

HIV/AIDS: Referral for Medical Nutrition Therapy

The RD should collaborate with other health care professionals, administrators and public policy decision-makers to ensure that all people with HIV infection are referred for Medical Nutrition Therapy (MNT) based on nutritional risk. The timeline for referral of patients categorized by nutritional risk is as follows: High risk, to be seen by an RD within one week; moderate risk, to be seen by an RD within one month; low risk, to be seen by an RD at least annually.

The registered dietitian (RD) should include the following anthropometric measurements in the initial assessment: Weight, height and body mass index; for children, growth pattern indices.
In addition, measurements of body compartment estimates should also be included, such as circumference measurements (mid-arm muscle, waist, hip and waist-to-hip ratio) or measurements of body cell mass and body fat [measured with skinfold thickness measurements, dual energy X-ray absorptiometry (DXA), bioelectrical impedance analysis (BIA), or bioimpedance spectroscopy].
Baseline anthropometric measurements provide information for the nutrition assessment and the majority of research in men, women, children and adolescents reports that fat-free mass and fat mass are altered in people with HIV infection.

Strong

Imperative

HIV/AIDS: Assess Food/Nutrition-Related History

The registered dietitian (RD) should assess the food and nutrition-related history of people with HIV infection, including but not limited to:

Factors affecting access to food and food and nutrition-related supplies

Physical activity and function

Nutrition-related patient and client-centered measures

Several studies report variations in energy and nutrient intake in people with HIV infection, some were under- and over-estimated requirements. A clear understanding of food and nutrient intake will form the basis for the nutrition diagnosis, prescription and intervention.

Strong

Imperative

HIV/AIDS: Nutrition Assessment

The registered dietitian (RD) should assess the following for people with HIV infection:

Food/nutrition-related history, such as knowledge, beliefs and attitudes and factors affecting access to food and food/nutrition-related supplies (see also the Assess Food/Nutrition-Related History recommendation, click here)

Assessment of nutritional and medical status is crucial to quality nutrition care for every person living with HIV infection.

Consensus

Imperative

HIV/AIDS: Determining Energy Needs

The registered dietitian (RD) should use clinical judgment and consider several factors when determining the energy needs of adults and children with HIV infection to maintain a healthy body weight. Factors related to energy needs in people with HIV infection include age, gender, stage of disease, nutritional status, opportunistic infections and comorbidities, inflammation and effects of medications. Although research reports increased resting energy expenditure (as much as 5% to 17%) in people with HIV infection, total energy expenditure may be similar to that of healthy control subjects.

The registered dietitian (RD) should educate people with HIV infection, especially those who are severely immunocompromised (having CD4 levels less than 200 cells per mm3) and others involved in their care, about food and water safety. Studies report that people with HIV infection are more susceptible to foodborne illness and also lack knowledge regarding food safety.

Strong

Imperative

HIV/AIDS: Encourage Physical Activity

If not contraindicated, the registered dietitian (RD) should encourage physical activity for people with HIV infection. Studies report that performing constant or interval aerobic exercise, progressive resistance exercise or a combination of both, for at least 20 minutes per session at a frequency of three times per week is generally safe in adults with HIV infection and may lead to significant improvements in strength, endurance, cardiopulmonary fitness and reductions in depressive symptoms.

Strong

Conditional

HIV/AIDS: Treatment of Diarrhea/Malabsorption

For people with HIV infection who have diarrhea/malabsorption, the registered dietitian (RD) should encourage the consumption of soluble fiber, electrolyte-repleting beverages and medium-chain triglycerides (MCT) and decrease the consumption of foods that may exacerbate diarrhea. Studies of fat malabsorption reported that consumption of MCT resulted in fewer stools, decreased stool fat and weight and increased fat absorption.

Fair

Conditional

HIV/AIDS: Vitamin and Mineral Supplementation

If people with HIV infection can not meet their Recommended Dietary Allowance (RDA) levels for micronutrients through diet, the registered dietitian (RD) should recommend vitamin and mineral supplements, especially for calcium and vitamin D. Micronutrient deficiencies are common in HIV-infected individuals and studies report increased morbidity and mortality in those not taking vitamin supplementation.

Strong

Conditional

HIV/AIDS: Macronutrient Composition

The registered dietitian (RD) should prescribe an individualized diet with a macronutrient composition based on the Dietary Reference Intakes (DRI, 20% to 35% of calories from fat, 45% to 65% of calories from carbohydrate, 14g fiber per 1,000kcal and 10% to 35% of calories from protein)

In people with HIV infection, protein needs are highly individualized. Low-fiber/high-fat diets are associated with fat deposition, insulin resistance and obesity. Studies indicate that diets low in saturated and total fat resulted in reduced triglyceride levels, increased HDL-cholesterol levels and a lower risk of lipohypertrophy.

Fair

Imperative

HIV/AIDS: Macronutrient Composition for Hyperlipidemia

For people with HIV infection who have hyperlipidemia, the RD should encourage consumption of a cardioprotective dietary pattern tailored to the individual's needs to provide a fat intake of 25% to 35% of calories, less than 7% of calories from saturated fat, less than 1% of calories from trans-fatty acids and under 200mg of cholesterol per day

Research on several lifestyle modification interventions for the treatment of hyperlipidemia in people with HIV infection reports improvements in serum lipid profile. Studies indicate that diets low in saturated and total fat and including omega-3 fatty acids resulted in reduced triglyceride levels, increased HDL-cholesterol levels and a lower risk of lipohypertrophy.

Strong

Conditional

HIV/AIDS: Coordination of Care

For people with HIV infection, the registered dietitian (RD) should implement medical nutrition therapy (MNT) and coordinate care with an interdisciplinary team and community resources. The interdisciplinary team is composed of health professionals including, but not limited to: RDs, physicians, physician assistants, nurse practitioners, nurses, pharmacists, case managers, substance use disorders treatment providers, respiratory care practitioners, occupational therapists, physical therapists, speech therapists, exercise physiologists, dentists, mental health professionals and treatment adherence counselors. Community resources may include, but are not limited to, food assistance programs, support systems and recreational facilities. This approach is necessary to effectively integrate MNT into overall management for people with HIV infection.

Consensus

Imperative

HIV/AIDS: Educate on Presence of HIV in Breast Milk

The registered dietitian (RD) should educate women with HIV infection who are pregnant or lactating about the presence of HIV in breast milk.

In the United States and other parts of the world where replacement feeding is affordable, feasible, acceptable, sustainable and safe, breastfeeding by HIV-infected women (including those receiving antiretroviral drugs) is NOT recommended.

In certain international settings, where replacement feeding is not affordable, feasible, acceptable, sustainable and safe, the registered dietitian (RD) should refer to the World Health Organization (WHO) guidelines, as well as country-specific Ministry of Health or other locally adapted guidelines, when educating women with HIV infection who are pregnant or lactating.

Note: Since the evidence was not analyzed using ADA's evidence analysis methodology this recommendation was based on the references cited below and it is rated consensus meaning the Work Group concurs.

Consensus

Conditional

HIV/AIDS: Educate on Medications

For people with HIV infection who are prescribed medications, the registered dietitian (RD) should provide education regarding food and drug interactions, nutrition-related adverse effects and risk of teratogenicity. Adverse effects of medications, including metabolic complications, gastrointestinal disturbances, and compromised nutrition intake, may lead to non-adherence and/or resistance to the prescribed medication regimen and poor nutrition status.

Factors affecting access to food and food- and nutrition-related supplies

Physical activity and function

Nutrition-related patient and client-centered measures.

Several studies report variations in energy and nutrient intake in people with HIV infection. Some were under- and over-estimated requirements. A clear understanding of food and nutrient intake will form the basis for the nutrition diagnosis, prescription and intervention.

Strong

Imperative

H/A: Monitor and Evaluate Anthropometric Measurements 2010

Using the same methodology as in the assessment of anthropometric measurements, the registered dietitian (RD) should monitor and evaluate body weight and height, body mass index, body compartment estimates and for children, growth pattern indices. The majority of research in men, women, children and adolescents reports that fat-free mass and fat mass are altered in people with HIV infection.